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Physiotherapy Works: musculoskeletal disorders

File 118884Physiotherapists are clinically effective and cost effective at managing and treating patients with musculoskeletal disorders (MSDs)


Size of the problem (6)

  • Over 200 types of MSD
  • 1 in 4 UK adults affected by chronic MSDs
  • Low back pain is reported by 80% of people at some time in their life
  • MSDs are the most common reason for repeated GP consultation
  • 60% of people on long term sick leave cite MSDs as cause

Patients with MSDs are the largest patient population group treated by physiotherapists.

In 2010/11 in England, physiotherapy outpatient services managed 1.9 million adults with a first appointment and 4.8 million follow up appointments for MSDs.(1)

Rapid access to musculoskeletal physiotherapists can reduce the amount of time people are off sick and is vital in preventing a new acute problem becoming chronic and long lasting.(2)

Physiotherapists have pioneered innovative ways of providing speedy and appropriate access within existing services.

Self referral

The Quality, Innovation, Productivity and Prevention (QIPP) process in England has endorsed self-referral for MSDs to allow easier access to treatment.(3) It has been shown to not increase demand for physiotherapy in the long term and also reduces patient related costs; such as prescribing, X-rays, MRI and more expensive medical consultations.(2)

A Department of Health pilot showed savings of £25,207 per 100,000 of population.(2) Holdsworth et al(4) demonstrated that in Scotland, an episode of GP prompted self referral costs 10% less and full patient self referral costs 25% less than traditional GP referral for physiotherapy.

The English pilot(2) showed 41% of referrals came from the traditional GP route, 35.4% came from prompted self referral and 23.6% were full self referral.

This shows the potential for greater cost savings for three quarters of patients with MSDs if full self referral were properly promoted.

STarT Back Tool

Within the UK each year, up to 9% of adults see their GP about back pain.(5) 

Some patients have a simple ache which will correct itself whilst others will have a long standing pain. The evolution of ‘risk stratication’, where patients are screened to identify the risks which may affect their treatment outcome, allows patients to be directed to the treatment pathway they need rather than applying a one size fits all approach.

Keele University demonstrated that the STarT Back Tool for neck and back patients was clinically and cost effective. Signicantly improved outcomes at four months and £34.39 saving per patient was shown when comparing the STarT Back intervention group with those who received usual care.(7)

The STarT Back method asks patients to fill out a questionnaire with the GP or physiotherapist. This identies whether the risks that may affect the treatment outcome are low, medium or high. The STarT Back questionnaire takes into account the patient’s symptoms, their perception of their pain as well as how it is affecting their life. Patients can then be directed to an appropriate treatment pathway based on this assessment. The pathway may include greater emphasis on self management for low risk patients or greater management of psychological distress for high risk patients.(7)

Promoting self management

MSD physiotherapists manage 1.9 million new patients per year (1)

Musculoskeletal physiotherapists support self management.

Physiotherapists provide nationally or locally produced patient information booklets. GPs and other referrers should ask local physiotherapy services about self management tools which can be provided for suitable patients in primary care.

Providing self-management resources at an early stage can help avoid the need for referral to secondary care with its associated higher costs.


Speedy access to physiotherapy for people with MSDs is clinically and cost effective for the health service, for employers and society.

It prevents unnecessary GP and secondary care appointments as well as improving patients’ quality of life.

Case study

East Lancashire Hospitals NHS Trust (ELHT) – Physiotherapy Spinal ‘Drop In’ Service

Since 2009 the award winning ELHT team have been providing a ‘drop in’ spinal clinic. This was created following collaboration with patients, referrers and staff. The project was initiated following a local study of patients which asked how they would like to receive low back pain advice. 70% of patients said they would prefer a drop in service. ELHT now provide early assessment and advice to patients.
Patients receive an ‘invitation slip’ from their GP and can then drop in to any of the thirteen participating community clinics. This allows patients with low back pain to be seen locally and quickly without an appointment by specialist physiotherapists. After patients are assessed they can be directed to the most appropriate treatment pathway.


  • Patients choose when to attend at their convenience rather than experiencing the previous 20 week waiting list
  • 90% of the service’s patients treated without need for onward referral
  • Cost saving to the physiotherapy service of 9% per patient
  • NHS Health and Social Care Award winners for innovation.


1. Department of Health. Reference costs 2010-2011 publication. London: Department of Health; 2011.
2. Department of Health. Self referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. London: Department of Health; 2008.

3. The Chartered Society of Physiotherapy. Musculoskeletal physiotherapy: patient self-referral. NHS Evidence 2012.

4. Holdsworth LK, Webster VS, McFayden AK. What are the costs to NHS Scotland of self referral to physiotherapy? Results of a national trial. Physiotherapy. 2007;93:3-11.

5. Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. European Spine Journal. 2003;12(2):149-65.

6. Department of Health. Musculoskeletal Services Framework. London: Department of Health; 2006.le/d912f50f7ccd669eb0.pdf

7. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratied primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. The Lancet. 2011;378(9802):1560-71.

Further information

CSP Enquiry Handling Unit
Tel: 0207 306 6666


The CSP would like to thank Lesley Harper (Extended Scope Practitioner, East Lancashire Hospitals NHS Trust).


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