Introduction

Occupational burnout, which is described as emotional exhaustion and a lack of drive and commitment (Freudenberger, 1975), has become a prominent focus within the medical literature (De Hert, 2020; National Academies of Sciences Engineering and Medicine, 2019; Schaufeli & Greenglass, 2001). Although the emotional stress that human services personnel face, and their coping mechanisms, has a significant impact on professional identities and workplace behaviour (Maslach, 1981), the World Health Organization recognises burnout as an ‘occupational phenomenon’ and excluded it as a medical condition in its 11th revision of the International Classification of Disease (World Health Organization, 2019).

A number of theoretical frameworks have been proposed to explain the development of burnout among human services personnel (Edú-Valsania et al., 2022). The Social Exchange Theory proposes that burnout is triggered by a lack of reciprocity or imbalance between professional efforts and rewards (Cropanzano et al., 2017). As a result, the interpersonal demands of patients become emotionally consuming for the practitioner who then develops depersonalisation, and ultimately low personal fulfilment as a result (Schaufeli et al., 2011; Schaufeli, 2006). The Social Cognitive Theory purports that burnout is triggered when the individual begins to doubt their own effectiveness in achieving their professional goals, leading to low professional fulfilment and the development of emotional exhaustion and cynicism as coping strategies (Manzano-Garcia & Ayala-Calvo 2013). Other theories of burnout development, including Organisational Theory, attribute burnout to organisational and work stressors. As a result of work overload, practitioners decrease their organisation commitment which, in turn, leads to depersonalisation, low personal accomplishment and emotional exhaustion (Golembiewski et al., 1983). Many of the components and outcomes of burnout development described in these theories can be measured among human services workers using the Maslach Burnout Inventory (MBI) (Maslach, 2001). This instrument is currently the most widely used and validated tool for assessing burnout across three dimensions of emotional exhaustion (EE), depersonalisation (DP) and personal accomplishment (PA). This tool is considered the gold standard for burnout assessment (Maslach, 1981; Rotenstein et al., 2018; Shi et al., 2019).

While research on burnout risk among health professionals has primarily focused on medical physicians (Marques-Pinto et al., 2021; McKinley et al., 2020), allied health practitioners make up the majority of the health care workforce. While allied health professions are often grouped under a broad umbrella, there are significant differences across the roles and care each vocation provides. Musculoskeletal-based professions, including chiropractors, occupational therapists, physical therapists, and podiatrists, work collaboratively to restore movement and function alongside treating injury, illness, and disability. The occupational tasks vary across these professions based on their specific areas of expertise and training (Online Resource 1). For example, chiropractors assess, treat and care for patients by manipulation of the spine and musculoskeletal system; occupational therapists assess, plan and organise rehabilitative programs for people with disability or development delays; physical therapists assess, plan, organise, and participate in rehabilitation programs for people with disease or injury; and podiatrists diagnose and treat diseases and deformities specific to the lower limb and foot. Despite these task-related differences, these musculoskeletal allied health professionals share many common occupational activities including active listening and social perceptiveness which allow them to identify, understand, and solve the often complex needs of their patients (National Center for O*NET Development (2023). As a result of these shared occupational activities, musculoskeletal allied health professionals share a number of occupational attributes which are centred in empathy, idealism, and selflessness allowing them to provide both physical and emotional support to patients, as well as endure depressive and aggressive patient behaviours (Paans et al., 2013). Their occupational activities require them to accept criticism and deal calmly and effectively with high-stress situations. In addition to dealing with heavy workloads, musculoskeletal allied health professionals have further daily responsibilities related to working within collaborative rehabilitation teams which requires additional energy in providing services and communicating with colleagues (Babiker et al., 2014). These factors may place them at a greater risk for burnout.

Burnout is associated with a number of consequences that directly impact professional performance associated with negative feelings about patient encounters. This heightens the risk of medical errors and suboptimal patient care practices (Aiken et al., 2002). Consequently, patients may experience longer recovery times, poorer health outcomes, and greater dissatisfaction with healthcare services (Welp et al., 2015). Burnout is also correlated with reduced job satisfaction and commitment leading to increased staff turnover, attrition, absenteeism and early retirement (Lee & Ashford, 1996; Paris & Hoge, 2010). Depersonalisation in particular, has been shown to predict occupational turnover in human services personnel (Leiter & Maslach, 2009). These consequences are detrimental to organisational productivity while being associated with significant economic costs (Han et al., 2019).

Numerous studies have investigated burnout among allied health professionals (Balogun et al., 2002; Cantu et al., 2021; Gibb et al., 2010; Mandy, 2004; Peterson et al., 2008; Rubin et al., 2021; Teo et al., 2021), however, the extent of clinician burnout across musculoskeletal allied professions has not been synthesised systematically. Therefore, this systematic literature review and meta-analysis aims to determine the prevalence and severity of burnout among musculoskeletal allied health clinicians according to the three dimensions of burnout– EE, DP, and PA.

Methods

Study Design

This study was a systematic review and meta-analysis of prevalence and severity of burnout risk among musculoskeletal allied health professionals. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Liberati et al., 2009). This statement encompasses a set of research-informed guidelines for use when conducting systematic reviews and meta-analyses to facilitate transparent reporting of the purpose of the review, the methods adopted, and the conclusions drawn from the results.

Search and Screening Strategy

The search was undertaken in October 2022 and updated in August 2023. The following databases were searched: Ovid Medline, CINAHL, and Scopus, with no limitation on publication year, using the following search term: (burnout OR “burn* out”) AND (“allied health” OR chiropract* OR “occupational therap*” OR podiatr* OR chiropod* OR “physical therap*” OR physiotherap*).

All identified studies were exported into Rayyan, an online systematic review application (Johnson & Phillips, 2018). After duplicate removal, two reviewers (MC, SS) independently screened titles and abstracts of all identified studies against the following inclusion criteria: original research studies of a quantitative or mixed methods design which report clinician burnout risk among musculoskeletal allied health professions (chiropractor, occupational therapist, physical therapist, and podiatrist ((ASAHP) Association of Schools Advocating Health Professions, 2015). To ensure consistency across data analysis and interpretation only studies which employed the gold standard MBI to measure burnout were included.

Studies were excluded if they were a non-English publication; included only medical, midwifery, nursing, or non-musculoskeletal allied health professionals; were case reports, case series, commentary letters, conference abstracts or review articles; employed burnout tools other than the MBI; or were of a qualitative study design. Studies reporting data presented in an already included study were excluded. Two independent reviewers (SS, MC) screened the full text of all included studies against the above criteria. Any differences were resolved with a third reviewer (MF).

Maslach Burnout Inventory (MBI)

The original and most extensively used version of the MBI is the MBI-Human Services Survey (MBI-HSS). The creation of this 22-item inventory is directed towards human services personnel, and it assesses the risk of developing burnout according to the three domains of burnout development: emotional exhaustion (MBI-EE, nine items), depersonalisation (MBI-DP, five items) and personal accomplishment (MBI-PA, eight items). Importantly, the MBI-HSS was developed to measure burnout on a continuum (i.e., one’s risk of developing burnout) and was not designed to provide a concrete diagnosis. Similar to the MBI-HSS, the MBI-General Survey (MBI-GSS) involves 22 items across three domains, which although named differently, parallel those in the MBI-HSS: exhaustion (MBI-EX, nine items), cynicism (MBI-CY, five items), and personal efficacy (MBI-PE, eight items). For the purpose of this review, studies using either version of the MBI were analysed together under the MBI-HSS domain names. The item scores are summated to provide total mean scores for each domain. High scores for MBI-EE and MBI-DP and low scores for MBI-PA indicate a greater risk of developing burnout. Using various cut-points, the scores can also be used to determine the prevalence of low, moderate, or high burnout (Maslach et al., 1997). However, it is recommended that the MBI scores be viewed on the continuous scale due to the lack of diagnostic validity in using cut-points, which have been removed from the latest MBI manual. Despite this, published studies using this tool continue to use cut-points to report their results, and were therefore included in the current analysis. Importantly, these cut-points were interpreted as having a low, moderate or high risk of developing burnout, as opposed to having a definitive diagnosis of burnout. Although cut-points vary across the literature, the most widely used cut-points were considered for the current analysis: < 16 (low), 17–26 (moderate), and ≥ 27 (high) for the MBI-EE domain; < 6 (low), 7–12 (moderate), and ≥ 13 (high) for the MBI-DP domain, and ≥ 38 (low), 33–37 (moderate), ≤ 32 (high) for the MBI-PA domain (Maslach et al., 1997).

Quality Assessment

The methodological quality of the included studies was assessed using the 14-item National Health Lung and Blood Institute (NHLBI) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (National Heart Lung and Blood Institute, 2021). Satisfied items scored a ‘yes’, items not satisfied scored a ‘no’, items which were not reported and therefore could not be determined were scored as ‘not reported,’ and those that were not applicable, ‘NA’. Two authors (MC, SS) independently scored the included studies using the NHLBI guidance document to assist with interpretation and scoring of each item. Any disagreements were resolved by a third author (MF).

Data Extraction

Data from all included studies were extracted into a standardised Microsoft Excel spreadsheet. A reliability exercise was undertaken by two reviewers (MC, SS) involving ten randomly selected studies to ensure consistency with data extraction. Following this, a single reviewer (MC) then extracted all data. The following characteristics were extracted: study characteristics (first author surname, year of publication, country of study recruitment, sample population, setting of study sample, study design, data collection method), participant characteristics (description of allied health profession(s), sample size(s) (n), gender, age of participants (years), practice experience (years)), MBI details (version of inventory used, scoring system used, and domain cut-points used), and study results (raw data reporting mean MBI scores for each of the three domains, and prevalence of low, moderate, and high burnout risk for each of the three domains). For intervention studies, where burnout risk was assessed pre- and post-intervention, only baseline data were extracted.

Meta-analysis

Meta-analyses were undertaken using both categorical and continuous measures of burnout. Categorical measures of burnout were included from studies which reported the number of practitioners who had high emotional exhaustion, high depersonalisation and/or low personal accomplishment. Only data from studies which utilised the standard MBI cut-points were included for analysis (high MBI-EE ≥ 27, high MBI-DP > 12, and low MBI-PA < 31). Three meta-analyses using categorical data were conducted to represent each of the three MBI domains. From these analyses, the pooled prevalence and 95% confidence interval were reported. For meta-analysis of the continuous measures of burnout, data were included from studies which reported the mean total scores and standard deviations from participants for each of the three domains of the MBI. Three meta-analyses using continuous data were conducted as above and the pooled mean prevalence and 95% confidence interval were reported.

Heterogeneity for all meta-analyses was examined using the I2 statistic and random effects models were used for all I2 > 0% in accordance with recommendations by the Cochrane Collaboration (Higgins et al., 2019). The random effects model allows representation of all studies (regardless of variable effect sizes) in the pooled estimates by weighting studies based on the ratio of within-study and between-study variance (Borenstein et al., 2010). Forest plots were generated to provide visual representations of the pooled estimates and their 95% confidence intervals. Although musculoskeletal allied health professionals share occupational attributes, the distinct tasks and activities each profession undertakes varies (National Centre for O*Net development, 2023) and it is unknown whether this variation may translate into variation in burnout risk. Therefore, to explore possible differences in the risk of burnout development between health care professions, a sub-group analysis by occupation was also undertaken. In addition, a subgroup analysis by geographical location (continent) was performed due to global differences in healthcare systems and their potential contribution to differences in burnout risk (Balogun et al., 2002; Fila & Wilson, 2018; Fish et al., 2022; Narayanan et al., 1999; Teo et al., 2021; Woo et al., 2020). All meta-analyses were performed in RStudio (version 4.1) using the metaprop command and a significance level of < 5%.

Results

Study Selection/Search Outcome

The initial literature search identified a total of 2,374 studies. After removal of duplicates and screening of titles and abstract, 123 full-text studies were screened. Of these, 69 did not meet the inclusion criteria, leaving a total of 54 studies included in the review (Fig. 1).

Fig. 1
figure 1

PRISMA flowchart of the systematic literature review process

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Characteristics of Included Studies and Participants

Characteristics of the 54 included studies are shown in Online Resource 2. All but one study employed a cross-sectional design. Studies were published between 1987 and 2023. The included studies examined burnout among musculoskeletal based allied health professions, comprising physical therapists (n = 23 studies), occupational therapists (n = 21 studies), chiropractors (n = 2 studies), and podiatrists (n = 1 studies). Six additional studies included both occupational therapists and physical therapists, and one study included occupational therapists, physical therapists, and podiatrists. Studies were conducted in 19 different countries across six continents. The majority of studies were from North America (n = 18, 33.3%) and Europe (n = 18, 33.3%). Ten studies (18.5%) were from Asia, 3 (5.6%) were from Oceania, and 3 studies (5.6%) from Africa. One additional study (2.2%) involved practitioners from both Europe and Oceania. Total sample sizes ranged from 13 to 1,162 participants. Practitioner experience varied from student to > 31 years.

Quality Assessment

A summary of the overall results from the NHLBI quality assessment are shown in Online Resource 3, with individual study data shown in Online Resource 4. All studies (n = 45, 100%) provided a clearly stated research question, while only 24 (44.4%) studies provided a clear description of the study population, including demographics, location and time period.in which they were selected or recruited. The majority of studies (n = 44, 81.5%) provided a sufficient description of the participant eligibility criteria and applied it consistently to all participants recruited for the study. Just over half (n = 31, 57.4%) of included studies provided sample size calculations or effect size estimates which is important to establish whether the study was powered to detect an association if one existed. Almost all studies (n = 43, 79.6%) assessed the influence of practitioner factors on burnout (including qualifications, years of practice, workplace conditions, or type of therapist) which greatly lends credibility to the hypothesis of causality. Almost half of studies (n = 25, 46.3%) reported recruiting only practitioners who were registered or licensed with a professional governing body which ensures that the occupation of all participants was defined accurately and reliably. Over one third (n = 22, 40.7%) of studies statistically explored potential confounding factors influencing burnout in addition to presenting the prevalence and/or severity of burnout using descriptive statistics. Due to the cross-sectional nature of the majority of included studies, items relating to assessment over time, blinding and loss to follow up were not applicable for all but one study, and items related to timing of assessment and sufficient timeframes were all scored as ‘no’ for cross-sectional studies.

Maslach Burnout Inventory

The original MBI-HSS was used by the majority of included studies (n = 49, 90.7%), while five (9.3%) studies used the MBI-GS. The 22-item version of the inventory was used by all but two studies which adopted a modified 16-item version (Online Resource 5). Item scoring was fairly consistent across studies, with 51 (94.4%) studies using the 7-point likert scale (ranging from 0 to 6), and two (3.7%) studies using a 5-point likert scale. Item scoring in the remaining one study was not clear. All studies calculated total domain scores by summing the scores from all items in each domain, and of these, six (11.1%) studies then divided the summated scores by the number of items in each domain. Included studies reported the mean scores for each of the three MBI domains and/or the number of participants classified as having low, moderate, or high burnout risk scores for each domain. For the latter, a range of cut-point definitions were used to classify participants (Online Resource 5). Table 1 summarises the burnout findings by health profession.

Table 1 Summary of burnout assessment and findings from included studies (n = 64)
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Meta-analyses

Pooled Prevalence of Burnout Risk Among Musculoskeletal Allied Health Professionals (Using the Categorical Measure of Burnout)

Nineteen studies reported the prevalence of high burnout risk across the three domains of the MBI. However only 12 of these studies used consistent scoring and cut-off scores and could be included in the meta-analyses (Online Resource 5). The total sample of musculoskeletal allied health professionals from these 12 studies was 3,119 (including 1,252 chiropractors, 1,636 physical therapists, and 106 occupational therapists), with 2,013 from North America, 739 from Europe, and 367 from Africa.

High Emotional Exhaustion

The pooled prevalence of high MBI-EE was 0.40 (95% confidence interval (CI) 0.29, 0.51) (Online Resource 6, Table 2). Subgroup analyses by health profession, showed that physical therapists and occupational therapists had a significantly higher prevalence of high MBI-EE compared to chiropractors (P < 0.001), while no significant differences were observed by continent (P = 0.49) (Table 2).

Table 2 Meta-analyses for pooled prevalence of MBI subscale scores
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High Depersonalisation

The pooled prevalence of high MBI-DP was 0.26 (95% CI 0.07, 0.53) (Online Resource 6, Table 2). Subgroup analyses showed that the prevalence high MBI-DP was significantly higher in physical therapists compared to chiropractors and occupational therapists (P = 0.02), and no significant differences were observed by continent (P = 0.59) (Table 2).

Low Personal Accomplishment

The pooled prevalence of low MBI-PA was 0.25 (95% CI 0.05, 0.53) (Online Resource 6, Table 2). Subgroup analyses showed that chiropractors had the highest prevalence of low MBI-PA compared to occupational therapists and physical therapists (P < 0.001), with no significant differences evident between continents (P = 0.92) (Table 2).

Pooled Mean Burnout Risk Scores Among Musculoskeletal Allied Health Professionals (Using the Continuous Measures of Burnout)

Forty-six studies reported mean scores for the three domains of the MBI (Online Resource 5). Of these, three studies were excluded from the meta-analyses because SDs were not provided for mean scores. Three additional studies were excluded because 5-point or 6-point likert scales were used for item scoring, as opposed to the traditional 7-point likert scale. Three more studies were excluded because they used a 16-item modified version of the original 22-item inventory. One further study was excluded because the reported mean scores exceeded the maximum range of possible scores (the author could not be contacted). Two final studies were excluded because a different method was used to calculate the final scores. Therefore, a total of 35 studies were included in the meta-analyses of pooled mean MBI domain scores. The total sample of musculoskeletal allied health professionals from these studies was 7,255 (including 4,143 physical therapists, 1,735 occupational therapists, and 1,252 chiropractors). Five studies were from Asia, 13 from Europe, 15 from North America, one each from Oceania and Africa.

Emotional Exhaustion

The pooled mean MBI-EE score was 23.13 (95% CI 21.48, 24.78) indicating a moderate level of burnout risk (Online Resource 7, Table 3). Subgroup analyses showed significant differences by health professional, with chiropractors experiencing the lowest mean MBI-EE scores and physical therapists and occupational therapists highest (P < 0.001) (Table 3). There was also a significant difference in mean MBI-EE scores across continents, with practitioners in Africa and Asia experiencing the highest mean MBI-EE scores (P < 0.001) (Table 3).

Table 3 Subgroup meta-analyses by health professional for MBI mean subscale scores
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Depersonalisation

The pooled mean MBI-DP score was 7.94 (95% CI 6.64, 9.23) indicating a moderate level of burnout risk (Online Resource 8, Table 3). As with the previous MBI domain, mean MBI-DP scores were lowest in chiropractors, while physical therapists reported the highest (P < 0.001) (Table 6). Practitioners from Africa reported the highest mean MBI-DP scores, while practitioners from Oceania reported the lowest (P < 0.001) (Table 3).

Personal Accomplishment

The pooled mean MBI-PA score was 35.89 (95% CI 34.03, 37.75) indicating a moderate level of burnout risk (Online Resource 9, Table 3). Again, subgroup analysis by health professional showed chiropractors reported the lowest burnout risk, with the highest scores, while physical therapists and occupational therapists reported the lowest scores, and therefore greatest burnout risk (P < 0.001) (Table 3). There was also a significant difference in mean MBI-PA scores across continents with Africa reporting the highest (and therefore lowest burnout risk) scores, and Asia and Europe the lowest (and therefore highest burnout risk) scores (P = 0.002) (Table 3).

Discussion

This is the first study to systematically review the prevalence and severity of burnout risk among musculoskeletal allied health practitioners. Burnout risk was common, with mean scores indicating moderate burnout risk across all three domains of the MBI (emotional exhaustion, depersonalisation, and personal accomplishment). Significant differences were also observed between health professionals, with physical therapists experiencing the greatest overall burnout risk and chiropractors the lowest. Geographical differences were also observed in the prevalence and severity of burnout risk.

Emotional exhaustion, was experienced by over a third (40%) of musculoskeletal allied health practitioners in this review, while high depersonalisation was experienced by just over a quarter (26%). These findings are consistent with pooled estimates reported in meta-analyses of other health professionals, including mental health professionals, paediatric nurses, oncologists, psychiatrists, radiation therapists and oncologists, dentists, and primary care workers, in which the prevalence of high emotional exhaustion ranges from 28 to 29%, and high depersonalisation from 15 to 19%. (Online Resource 10). Emotional exhaustion leads to feeling overburdened and depleted of emotional and physical resources, leading to a loss of enthusiasm for work. Although many musculoskeletal allied health professionals felt emotionally exhausted and cynical towards others, this did not appear to impact their feelings of personal accomplishment, with a pooled 25% of participants classified as having low personal accomplishment. This is considerably lower than many other healthcare professionals, in which recent meta-analyses have indicated prevalence rates of low personal accomplishment reaching up to 46% among intensive care nurses (Online Resource 10), which may be attributed to their longer work hours (Filho et al., 2019). However, reduced personal accomplishment is often considered a consequence rather than a defining feature of burnout (Kristensen et al., 2005). Although these results suggest that high burnout among musculoskeletal allied health professionals may not substantially impact their feelings of competence and successful achievement in their work (Maslach et al., 2001), it may also suggest that they may not yet have progressed to this stage of the burnout continuum.

In the current review, physical therapists had the greatest burnout risk across all three domains of the MBI, while chiropractors had the lowest. The reasons for differences between these professions is not clear but may be attributed to a range of varying work-related factors unique to each profession. Although both physical therapists and chiropractors share many common occupational tasks, activities and attributes, physical therapists (unlike chiropractors) carry an additional role as an ‘instructor’ which requires them to implement learning strategies to teach and coach patients and their families through rehabilitation programmes that often take place outside of the clinic environment (i.e., within the patient’s home) (National Centre for O*Net Development, 2023). However, further research is required to determine whether the added responsibility in ensuring the patient’s management and care is continued outside of the clinic environment contributes to greater demands on the physical therapist and therefore a greater risk of developing burnout. Previous studies have also identified several work-related factors that are strongly associated with burnout among other allied health professionals, including varying administrative duties, practice settings, shift patterns and working hours, workplace conflicts, and varying philosophical perspectives within the professions (Elbarazi et al., 2017; Saura et al., 2022; Williams et al., 2013). Younger practitioners or those with less work experience have also been reported to experience greater burnout due to less advanced coping strategies (Hsu, 2018; Saura et al., 2022; Teo et al., 2021). This may have implications for future workforce development and the unmet need of allied health care professionals.

The findings from this review have also highlighted that burnout risk among musculoskeletal allied health professionals is a global phenomenon. However, subgroup analyses suggest that the prevalence and severity of burnout risk may demonstrate geographical differences. Observed differences were dependent on the MBI domain being assessed, with practitioners from Africa and Asia experiencing the highest emotional exhaustion and depersonalisation and practitioners from Asia and Europe experiencing the lowest sense of personal accomplishment. Asian representation across all three burnout domains is consistent with the higher reporting of burnout among Asian nurses compared to other geographical locations (Woo et al., 2020). Many Asian countries are impacted by huge health workforce shortages (World Health Organization, 2018), along with rapid economic growth, urbanisation, and an aging population, which increases the demand for healthcare and may impact burnout among practitioners (Ramesh & Wu, 2008; Sheikh et al., 2017). Cultural differences may also play a role in this. For example, the traditional Chinese attitude towards working or fulfilling one’s duty is to withstand hardship without complaint, making one more prone to developing burnout (Lo et al., 2018). Similarly, higher rates of burnout have also been reported among healthcare workers in Africa which has been associated with less support or resources to management workloads (Levert et al., 2000; Dubale et al., 2019).

Although this review was conducted in line with the PRISMA guidelines (Liberati et al., 2009) to ensure methodological rigour, there are a number of limitations that warrant consideration. Firstly, non-English publications were excluded; and although the current review included a diverse range of populations from across the globe, the results may not reflect true global differences in burnout among non-English speaking countries. Secondly, many of the included studies involve small sample sizes and extensive variance in study quality which should be considered in light of the results. Thirdly, although there are several tools used to assess burnout risk, only studies utilising the MBI were included due to analytical consistency. Furthermore, a number of studies were excluded from the meta-analyses due to variations in cut-points and scoring systems used. Additionally, physical therapists and occupational therapists were reasonably well represented within this review, yet few studies reported data on chiropractors and podiatrists. This may limit the ability to comment and draw conclusions specifically on these professions. Finally, the included studies were cross-sectional in nature, and longitudinal observations may be required to explore the impact of emotional exhaustion and depersonalisation on the development of reduced personal accomplishment in practitioners over a longer period of time.

Although beyond the scope of this review, the impact of COVID-19 on healthcare worker burnout is undeniable (Bradley & Chahar, 2020; Leo et al., 2021). Due to the timing of this review in relation to the pandemic, only four COVID-19-specific studies were included, limiting the ability to draw accurate conclusions on this issue. Further research may also explore factors contributing to the varying levels of burnout risk observed between different musculoskeletal allied health professions and geographical locations, which would facilitate the development of more targeted and effective burnout interventions. Intervention strategies for healthcare worker burnout can be organisation-directed or individual-directed, or a combination of the two (Awa et al., 2010). Such interventions have been shown to result in a range of positive outcomes among healthcare workers, including improving well-being, work engagement and quality of life, while reducing burnout, stress, anxiety and depression (Cohen et al., 2023). Although a recent systematic review suggests that organisational-level interventions may be more effective in targeting healthier workplaces (Cohen et al., 2023), from a feasibility perspective, they are more difficult to implement (Fox et al., 2022).The most commonly studied interventions targeting healthcare worker burnout have therefore been at the individual-level, including mindfulness, stress management, and small group discussions, which have all be shown to be effective approaches in reducing burnout (West et al., 2016). Organisational-directed measures involve system level changes, such as task restructuring or work evaluation and supervision which aim to decrease job demand or increase job control. In fact, burnout research among physical therapists demonstrated only one third were offered clinical supervision and support by their employer and the authors suggested that more support in the workplace and during training may prevent burnout development among this profession (Fischer et al., 2013).

In conclusion, this systematic review and meta-analysis has demonstrated that musculoskeletal allied health professionals frequently experience a risk of burnout related to emotional exhaustion and depersonalisation. However, feelings of lower personal accomplishment, which develop later in the burnout continuum, are observed in fewer practitioners. Differences in burnout risk prevalence and severity were also evident among professions and geographical locations, suggesting that tools aimed at addressing burnout should be tailored toward the practitioners’ vocation and cultural position.