Consultation skills - When should I refer to a physiotherapist?

Dr Lizzie Croton examines the role of physiotherapy in two common musculoskeletal conditions.

Physiotherapists are healthcare professionals concerned with human movement and function. They aim to maximise the potential of patients under their care.

Physiotherapist manipulating the cervical region of a patient’s spine during spinal mobilisation therapy (photograph: SPL)

With budget limitations it is essential that we use these services wisely by referring only those patients who are likely to benefit.

Centrally located guidelines are useful in guiding clinical decisions. This enables referral of the right patient at the right time in the course of the patient's medical treatment.

Most primary care organisations access physiotherapists via dedicated referral forms and the GP must indicate the urgency of the referral on the paperwork.

If the doctor is unsure as to whether physiotherapy will work, or what treatments can be offered, it is helpful to ring the physiotherapy team for advice.

With recurring conditions, the patient's medical history can show whether the condition has responded to physiotherapy before.

Mechanical low back pain
Mechanical back pain accounts for 85-90 per cent of lower back pain and cannot be ascribed to any particular pathology.

A patient presenting with acute back pain should be told to avoid bed rest. Analgesia should be given and the patient advised to maintain normal activity.

NSAIDs and paracetamol are the best form of analgesia because of the adverse effects of codeine-based medications.

Despite being such a common problem, there are few good-quality, randomised controlled trials for back pain management and many conflicting results.

A review from 2002 suggested simple analgesics had short-term benefits in the acute phase together with spinal manipulation if performed in the first four weeks.1

There was no evidence for traction and back schools. Exercise led to a more rapid recovery, whereas bed rest was ineffective.

There is little evidence for the value of physiotherapy in lower back pain. This may be because more than one modality is employed at once.

A Cochrane review suggested little benefit for traction, and physiotherapy stabilising exercises were only marginally better than pharmacological treatment.2

Manipulation (usually provided by chiropractors or osteopaths) is associated with few adverse effects despite a 2004 Cochrane review suggesting that manipulation was no better than standard treatments.3

Treating patients with back pain requires careful attention to adequate pharmacological measures, together with encouraging exercise and an awareness of the patient's psychosocial background.

For most patients, pain will reduce rapidly within one month and 75 per cent will be back at work by this stage. Referral to a physiotherapist may be considered if a patient is still having symptoms at six weeks.

Alternatively, patients may self-refer to a chiropractor for manipulation but ideally this should be within four weeks of the onset of symptoms.

Whiplash neck sprains
A whiplash injury involves a flexion/extension soft tissue injury of the cervical spine. This is commonly caused by a road traffic accident but can be caused by assault or sports injuries.

There are two types of whiplash injury.

The first involves cervical hyperextension, where a slow moving or stationary vehicle is hit from behind. The body is thrown forward and the head lags, resulting in cervical hyperextension. The neck then snaps into flexion.

The second involves a rapid deceleration injury throwing the head forward and flexing the cervical spine.

Forward flexion is limited by the chin but the resulting movement may be sufficient to cause longitudinal distraction and neurological damage.

Typical features of whiplash include neck pain, jaw pain, paraspinal muscle tightness and spasm. The neck pain typically develops six to 12 hours after the insult and reaches its peak one to two days post injury.

Recovery is best aided by the patient taking an active role in dealing with their symptoms. Regular analgesia such as NSAIDs should be provided and the use of collars discouraged. There is now good evidence that they prolong recovery.4

Patients should be advised about neck mobilisation and encouraged to remain as active as possible. They should also receive information about specific neck exercises.

A recent study comparing patient education by GPs or physiotherapists found no significant differences in overall outcome.5 In particular, the long-term effects of GP care compared with physiotherapist care were superior with regards to functional recovery, coping and physical functioning.

Physiotherapist care was more effective than GP care with regards to cervical range of motion at short-term follow-up.

Patients with whiplash injuries should be reviewed regularly following the injury, and physiotherapy referral should be considered in those with particularly severe symptoms, such as paraesthesia, which are not starting to resolve seven days after the injury.

Physiotherapy is most effective if it is started within three weeks of the injury. There is also some limited evidence for beneficial results using acupuncture6 and chiropractic treatment7 in whiplash injury.

  • Dr Croton is a salaried GP in Birmingham
This topic falls under section 15.9 of the RCGP curriculum 'Rheumatology and conditions of the musculoskeletal system', www.healthcarerepublic.com/curriculum

Learning points

1. Aim to refer only those patients who are likely to benefit from physiotherapy, and at the optimum time in their management.

2. There is little evidence that physiotherapy is beneficial to patients with lower back pain.

3. Patients with mechanical low back pain should be given analgesia and advised to maintain normal activity.

4. Physiotherapy may benefit patients with severe whiplash.

References

1. Smith D, McMurray N, Disler P. Early intervention for acute back injury: can we finally develop an evidence-based approach? Clin Rehabil 2002; 16(1): 1-11.

2. Clarke J, van Tulder M, Blomberg S et al. Traction for low back pain with or without sciatica: an updated systematic review within the framework of the Cochrane collaboration. Spine 2006; 31(14): 1,591-9.

3. Assendelft W J, Morton S C, Yu El et al. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev 2004; (1): CD000447.

4. Rodriquez A A, Barr K P, Burns S P. Whiplash: pathophysiology, diagnosis, treatment and prognosis. Muscle Nerve 2004; 29(6): 768-81.

5. Scholten-Peeters G G, Neeleman-van der Steen C W, van der Windt D A et al. Education by general practitioners or education and exercises by physiotherapists for patients with whiplash-associated disorders? A randomized clinical trial. Spine 2006; 31(7): 723-31.

6. Witt C M, Jena S, Brinkhaus B et al. Acupuncture for patients with chronic neck pain. Pain 2006; 125(1-2): 98-106.

7. Woodward M N, Cook J C, Gargan M F et al. Chiropractic treatment of chronic 'whiplash' injuries. Injury 1996; 27(9): 643-5.

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