Many times when I tell people that I’m a musculoskeletal physiotherapist or an “MSK” physio they nod uncertainly and wait for me to elaborate. Fair enough for those who don’t know the abbreviation “MSK”, but what musculoskeletal encapsulates, and what a musculoskeletal physiotherapist does is very important to understand. Here’s why.
Who does it affect?
Public Health England found musculoskeletal conditions to be highly prevalent at 30% of the whole population of England at one given time in 2017. Not only that but they found that it is the leading cause for pain and disability in England, and one of the highest causes of sickness absence and productivity loss.
Define musculoskeletal conditions
Both NHS England and World Health Organization (WHO) defines musculoskeletal conditions as a condition which affects the joints, bones, muscles and sometimes associated tissues such as nerves. These may be temporary issues or lifelong impairments depending on what, how and to what degree it is affected. WHO states that there are over 150 MSK conditions, with a tiny handful of examples including twisting an ankle when playing rugby, fracturing a hip after falling, aching and numbness running down the leg (also known as sciatica), pain appearing in the thumb after using the mouse, whiplash.
What role does MSK physiotherapy play?
Physiotherapy has a major role to play in MSK conditions. An experienced MSK physiotherapist will be able to diagnose, treat, manage, educate, and appropriately refer a patient who comes to them with a musculoskeletal condition. A systematic review by Desmeules et al (2012) examined the effectiveness of highly trained MSK physiotherapists in the diagnosis, treatment, economic evaluation of treatment, and patient satisfaction for musculoskeletal disorders in comparison to general practitioners. Astonishingly to many they found these highly trained MSK physiotherapists "may be as (or more) beneficial than usual care by physicians for patients with musculoskeletal disorders, in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction."
What other professions are involved in MSK care?
The main professionals involved in MSK care are physiotherapists, general practitioners and orthopaedic specialists. I will highlight that there are particular other professions involved in specialties or certain cases in MSK care such as orthopaedic nurses, podiatrists and occupational therapists. As they are involved in special care or certain cases, these professionals are often either referred to, or work within a greater team within the hospital MSK care and so will not be included as we discuss physiotherapy's role within MSK care.
How physiotherapy fits into the landscape of MSK care?
To understand the physiotherapist’s specific role in relation to general practitioners and orthopaedic specialists, we lay out the common pathway of care for musculoskeletal conditions that people take (figure 1):
When pain or functional limitation develops for a patient, they begin with self-management. Once this reaches its maximum effect, they then will escalate the issue to see a GP. A GP will detect that it’s an MSK issue, and then refer for a physiotherapist as the first line of treatments a GP can provide include pain relief and anti-inflammatory medication, and advice for exercise/rest. This is because a GP’s specialty is not to provide treatment for MSK issues but rather the physiotherapist. When seen by the physiotherapist, they will further assess and treat the complaint conservatively. For the majority of cases, this is where the MSK issue would resolve, however for those who can no longer improve and the issue is not a chronic one, the physiotherapist will either refer back to the GP for more invasive treatment such as corticosteroid injections or further investigation such as an X-ray; or refer directly to an orthopaedic specialist for invasive treatment. The orthopaedic specialist will then often refer back to physiotherapy once the invasive treatment is performed to assist the patient back to normal function.
An alternative to the common pathway?
The problem with this common pathway is that the GP acts as the gatekeeper to physiotherapy. Like any gate, this slows down the traffic and the result are long waiting lists. One might argue that the GP must be in place to screen out for issues that are not MSK. However, MSK physiotherapists are now well trained to screen for these so called “masqueraders” and refer to the GP if there is such an issue.
Let’s look here at the renewed idea of MSK pathway (figure 2):
As shown, the patient directly sees the physiotherapist when they appear to have an MSK issue they cannot solve by themselves. This removes the GP from the initial onset so they don’t need to act as gatekeeper for MSK issues thus removing up to 30% of their patient load. One may be concerned that the issue would then be reversed, having physiotherapists act as a gatekeeper and them having to just refer to the GP for many non-MSK issues. This is false as a lay person would generally be able to tell whether something is MSK related or not – a sprained ankle, tight and painful neck due to sitting in the office, a pulled shoulder. For those more complex conditions which the lay person is unsure whether it is MSK or non-MSK related, they can see either a physiotherapist or a GP as both will be able to assess far enough to point them to the other if needed.
Legitimate idea or physiotherapist going out of scope?
For anyone who is in doubt about this idea and may think I, as a physiotherapist, am pushing my own agenda, within the public system there is already a strong push towards physiotherapists being the first contact in musculoskeletal care. NHS England here shows exactly what I’ve mentioned above to help with offloading the system being too reliant on medical doctors when it comes to MSK care.
What might be barriers to this pathway?
I can think of two main barriers to this change of pathway:
1. The system working against it. Mentioned above we see that the NHS is working towards this change of pathway however even within the NHS there are certain referral pathways allowed by certain professionals. If a physiotherapist doesn’t have the authorization to refer a patient directly to a consultant such as an orthopaedic specialist, neurological specialist or request for certain investigations such as X-rays, MRIs; but instead, they have to refer back to a GP in order for them to refer onwards, then the whole point of reducing GP traffic has gone and the patient again finds themselves in a back-and-forth situation.
2. There is a lack of quality control in MSK physiotherapy. Physiotherapy is a broad study. MSK physiotherapy is only one of the many specialties that physiotherapy can work within. However, unlike medical doctors who require specific onward study along with many tests and examinations in specializing in certain fields, a physiotherapist’s hurdle into MSK physiotherapy is mainly the job interview and how well they can attract a case load. Of course, with time either the clinic will teach the physiotherapist or they won’t attract any sort of case load, but at that point the damage will have been done, reducing society’s trust in MSK physiotherapists in making proper judgement for diagnoses and providing sound treatment plans.
How does Chiropractic and Osteopathy fit in?
It is worth mentioning that there are other professions that work similarly to MSK physiotherapy: chiropractic and osteopathy. Both these other professions also deal with MSK issues often similar to how a physiotherapist would. I will investigate this in a future blog post, however in the mean-time I would say that within the public health system, physiotherapists are the recognized provider out of these three for MSK issues. See here on NHS for further information on chiropractic, and here for further information on osteopathy.
Now that we’ve introduced the MSK physiotherapist and how they work within the landscape of MSK management, we hope it will provide use next time you have an MSK issue. Rather than directly contacting the GP, go see an MSK physiotherapist or better yet, if you live in Abingdon-on-Thames, call the Abbey Mobile Physio to come see you!
References:
Desmeules F, Roy JS, MacDermid JC, Champagne F, Hinse O, and Woodhouse LJ 2012, Advanced practice physiotherapy in patients with musculoskeletal disorders: a systematic review, BMC Musculoskeletal Disorders, No. 107, Vol. 13
NHS England, 2022, First Contact Physiotherapists, Available at: https://www.england.nhs.uk/gp/expanding-our-workforce/first-contact-physiotherapists/ (Accessed 14 Dec 2022).
NHS England, 2022, Musculoskeletal Health, Available at: https://www.england.nhs.uk/elective-care-transformation/best-practice-solutions/musculoskeletal/ (Accessed 14 Dec 2022)
Office for Health Improvement and Disparities, 2022, Musculoskeletal Health: applying All our Health, Available at: https://www.gov.uk/government/publications/musculoskeletal-health-applying-all-our-health/musculoskeletal-health-applying-all-our-health (Accessed 14 Dec 2022)
World Health Organization, 2022, Musculoskeletal Health, Available at: https://www.who.int/news-room/fact-sheets/detail/musculoskeletal-conditions#:~:text=Musculoskeletal%20health%20refers%20to%20the,joints%20and%20adjacent%20connective%20tissues (Accessed 14 Dec 2022)
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