Musculoskeletal (MSK) conditions account for 18-35 per cent of consultations in primary care and are the second most common reason for GP visits.
Given this huge MSK burden and the general recognition that MSK training may be inadequate in undergraduate and postgraduate medical training,1,2 improved management of MSK conditions is required.
Many doctors are unaware that physiotherapists practise autonomously, do not require a GP referral and several operating frameworks have recommended that patients should self-refer to physiotherapy.
Research suggests however, that GPs often refer to physiotherapy to handover 'difficult patients', are not sure which patients to refer and that physiotherapy is poorly understood and not used to maximum effect by doctors.3
The role of physiotherapy
A formal definition of physiotherapy comes from the Chartered Society of Physiotherapy curriculum framework (2002), which suggests it 'uses physical approaches to promote, maintain and restore physical, psychological and social well-being, taking account of variations in health status'.
Physiotherapists have on average about 30 to 45 minutes per consultation to take a detailed history, and perform a clinical and functional examination. Compared with the average nine-minute GP consultation this places the physiotherapist at a distinct advantage in assessment and diagnosis of MSK problems.
While physiotherapists make diagnoses, focus is often on functional rehabilitation to enable patient well-being.
Like doctors, physiotherapists treat patients holistically and functionally.
Physiotherapists are also trained in biomechanics, neuroscience and pain, physiology, respiratory healthcare, trauma and orthopaedics, intensive care unit and critical care, care of the elderly, cardiac care, neurorehabilitation and much more.
Like GPs, many physiotherapists have special interests. Some physiotherapists can request investigations (scans and blood tests), refer directly to consultants, supplementary prescribe and even undertake surgery.
Numerous studies suggest that one of the main risk factors for an MSK problem is having had the same problem previously. A physiotherapist is trained to reduce the risk of re-injury and provide advice. This can be helpful to both the patient and the GP regarding activity modification and return to activity or sport.
Physiotherapy is appropriate for most MSK conditions.
However, like all NHS services, it is not an unlimited resource and waiting times are hugely variable. This places treatment challenges on GPs who are managing MSK conditions.
Paradoxically, it may occasionally be more appropriate to consider not referring to a physiotherapist.
Notwithstanding patient autonomy, the following list explores some of the considerations that should be made prior to referral, as each may have a negative effect on outcomes.
- Exclude red flags present to rule out serious conditions.
- Would referral elsewhere be more appropriate, for example, sport and exercise medicine specialist, a podiatrist or a pain clinic?
- Is the diagnosis correct? Has previous treatment not worked because the diagnosis has changed or an underlying cause was not addressed?
- Is podiatry/gait correction required to treat the underlying cause or enhance physiotherapy?
- If physiotherapy (or an osteopath/chiropractor) has not worked already, ask yourself why?
- Does the patient have negative perceptions of physiotherapy based on past experience?
- Unconfirmed or uncertain diagnosis.
- Is physiotherapist inexperience an issue for a given condition?
- Previous or expected patient non-concordance with physiotherapy advice.
- Will the condition get better if left alone or is there future injury risk?
- Is analgesia adequate and will the patient be able to undertake physiotherapy?
- Are there psychosocial issues affecting outcomes?
When referring to physiotherapy, it is useful to consider the five 'S's:
- Sinister pathology The GP should exclude this before referral.
- Second opinion Physiotherapists provide this service. However, an experienced colleague or sport and exercise medicine specialist may also provide a second opinion.
- Stop/slow down This could include advice to the patient about reducing activity. Physiotherapists provide this service, but can the doctor give appropriate management advice?
- Scans and investigations A GP should consider whether a diagnosis is required before referral to assist the physiotherapist.
- Surgery Is surgery the best appropriate treatment for the condition? Some audits suggest that only 20-25 per cent of orthopaedic outpatients undergo surgery. Given scarce commissioning resources, it may be worth considering the most cost effective and best patient care pathway model for your area.
Working with physiotherapists
A systematic review suggests that the information GPs give to patients prior to referral could be improved and used to enhance the non-specific (placebo) effects of treatment in a way that is ethical and optimises clinical outcomes.4 This seems obvious and logical. Rationally, if a patient does not understand the purpose of any treatment, then this will affect concordance and outcomes.
Therefore, better communication between doctor, patient and physiotherapist is needed to enhance patient outcomes.
To facilitate this, doctors should appropriately manage the patient's ideas, concerns and expectations.
To improve this process GPs should have a thorough understanding of local MSK and physiotherapy services and ensure good communication and relationships with local physiotherapists.
Given large variations in waiting times for physiotherapy it may help GPs to have access to physiotherapy patient information leaflets. These can be given to patients to ensure simple rehabilitation is commenced while they wait to be seen.
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Dr Weiler is a sport, exercise and musculoskeletal medicine physician and GP in London and Hertfordshire
1. Woolf A, Walsh N, Akesson K. Ann Rheum Dis 2004; 63: 517-24.
2. Al-Nammari SS, James BK, Ramachandran M. J Bone Joint Surg Br 2009; 91: 1413-8.
3. Clemence ML, Seamark DA. Fam Pract 2003; 20: 578-82.
4. Crow R, Gage H, Hampson S et al. Health Technol Assess 1999; 3: 1-96.